Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation

Emilie Vitel (1) , Elena Galli (1, 2) , Christophe Leclercq (1, 2) , Maxime Fournet (1) , Christian Bosseau (1) , Hervé Corbineau (2, 3) , Guillame Bouzille (2, 4) , Erwan Donal (1, 2)

1 Service de cardiologie et maladies vasculaires [Rennes] = Cardiac, Thoracic, and Vascular Surgery [Rennes]
2 LTSI - Laboratoire Traitement du Signal et de l'Image
3 Service de chirurgie thoracique cardiaque et vasculaire [Rennes] = Thoracic and Cardiovascular Surgery [Rennes]
4 CHU Pontchaillou [Rennes]

Objective - To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery. Methods - Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value. Results - After median follow-up of 30 months (IQR 16-60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7). Conclusion - Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.

Keywords: valve disease surgery; echocardiography; mitral regurgitation

Domains: Life Sciences [q-bio]; Human health and pathology; Cardiology and cardiovascular system; Life Sciences [q-bio]; Human health and pathology; Surgery; Life Sciences [q-bio]; Bioengineering

Emilie Vitel, Elena Galli, Christophe Leclercq, Maxime Fournet, Christian Bosseau, et al.. Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation. Heart, 2018, 104 (10), pp.855-860. ⟨10.1136/heartjnl-2017-312097⟩. ⟨hal-01806797⟩